{"id":1602,"date":"2023-08-13T23:37:18","date_gmt":"2023-08-13T23:37:18","guid":{"rendered":"https:\/\/starchoicepediatrics.com\/?page_id=1602"},"modified":"2023-08-13T23:43:56","modified_gmt":"2023-08-13T23:43:56","slug":"patient-registration-form","status":"publish","type":"page","link":"https:\/\/starchoicepediatrics.com\/?page_id=1602","title":{"rendered":"Patient registration form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"1602\" class=\"elementor elementor-1602\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-b8f890a elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"b8f890a\" data-element_type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-db4f082\" data-id=\"db4f082\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-9348de4 elementor-widget elementor-widget-shortcode\" data-id=\"9348de4\" data-element_type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\"><div class=\"forminator-ui forminator-custom-form forminator-custom-form-1601 forminator-design--default  forminator_ajax\" data-forminator-render=\"0\" data-form=\"forminator-module-1601\" data-uid=\"69d731a74f51d\"><br\/><\/div><form\n\t\t\t\tid=\"forminator-module-1601\"\n\t\t\t\tclass=\"forminator-ui forminator-custom-form forminator-custom-form-1601 forminator-design--default  forminator_ajax\"\n\t\t\t\tmethod=\"post\"\n\t\t\t\tdata-forminator-render=\"0\"\n\t\t\t\tdata-form-id=\"1601\"\n\t\t\t\t\n\t\t\t\tdata-design=\"default\"\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\tdata-grid=\"open\"\n\t\t\t\t\n\t\t\t\t\n\t\t\t\tstyle=\"display: none;\"\n\t\t\t\t\n\t\t\t\tdata-uid=\"69d731a74f51d\"\n\t\t\t><div role=\"alert\" aria-live=\"polite\" class=\"forminator-response-message forminator-error\" aria-hidden=\"true\"><\/div><div role=\"tablist\" class=\"forminator-pagination-steps\" aria-label=\"Pagination\"><\/div><div tabindex=\"0\" role=\"tabpanel\" id=\"forminator-custom-form-1601--page-0\" class=\"forminator-pagination forminator-pagination-start\" aria-labelledby=\"forminator-custom-form-1601--page-0-label\" data-step=\"0\" data-label=\"Finish\" data-name=\"page-break-1\"><div class=\"forminator-pagination--content\"><div class=\"forminator-row\"><div id=\"section-1\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Parents Details<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-2\" class=\"forminator-field-name forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-2_69d731a74f51d\" id=\"forminator-field-name-2_69d731a74f51d-label\" class=\"forminator-label\">Parent Name<\/label><input type=\"text\" name=\"name-2\" value=\"\" placeholder=\"E.g. John Doe\" id=\"forminator-field-name-2_69d731a74f51d\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" \/><\/div><\/div><div id=\"text-2\" class=\"forminator-field-text forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-2_69d731a74f51d\" id=\"forminator-field-text-2_69d731a74f51d-label\" class=\"forminator-label\">D.O.B.<\/label><input type=\"text\" name=\"text-2\" value=\"\" placeholder=\"\" id=\"forminator-field-text-2_69d731a74f51d\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"text-1\" class=\"forminator-field-text forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-1_69d731a74f51d\" id=\"forminator-field-text-1_69d731a74f51d-label\" class=\"forminator-label\">S.S.#<\/label><input type=\"text\" name=\"text-1\" value=\"\" placeholder=\"\" id=\"forminator-field-text-1_69d731a74f51d\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"address-1\" class=\"forminator-field-address forminator-col forminator-col-6 \"><div class=\"forminator-row\"><div id=\"address-1-street_address\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-street_address_69d731a74f51d\" id=\"forminator-field-address-1-street_address_69d731a74f51d-label\" class=\"forminator-label\">Street Address<\/label><input type=\"text\" name=\"address-1-street_address\" placeholder=\"E.g. 42 Wallaby Way\" id=\"forminator-field-address-1-street_address_69d731a74f51d\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\" data-multiple=\"false\"><div id=\"address-1-zip\" class=\"forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-zip_69d731a74f51d\" id=\"forminator-field-address-1-zip_69d731a74f51d-label\" class=\"forminator-label\">ZIP \/ Postal Code<\/label><input type=\"text\" name=\"address-1-zip\" placeholder=\"E.g. 2000\" id=\"forminator-field-address-1-zip_69d731a74f51d\" class=\"forminator-input\" value=\"\" \/><\/div><\/div><\/div><\/div><div id=\"phone-1\" class=\"forminator-field-phone forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-1_69d731a74f51d\" id=\"forminator-field-phone-1_69d731a74f51d-label\" class=\"forminator-label\">Home phone<\/label><input type=\"text\" name=\"phone-1\" value=\"\" placeholder=\"E.g. +1 300 400 5000\" id=\"forminator-field-phone-1_69d731a74f51d\" class=\"forminator-input forminator-field--phone\" data-required=\"\" aria-required=\"false\" autocomplete=\"off\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-1\" class=\"forminator-field-name forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-1_69d731a74f51d\" id=\"forminator-field-name-1_69d731a74f51d-label\" class=\"forminator-label\">Employer Name<\/label><input type=\"text\" name=\"name-1\" value=\"\" placeholder=\"E.g. John Doe\" id=\"forminator-field-name-1_69d731a74f51d\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" \/><\/div><\/div><div id=\"phone-2\" class=\"forminator-field-phone forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-2_69d731a74f51d\" id=\"forminator-field-phone-2_69d731a74f51d-label\" class=\"forminator-label\">Work phone<\/label><input type=\"text\" name=\"phone-2\" value=\"\" placeholder=\"E.g. +1 300 400 5000\" id=\"forminator-field-phone-2_69d731a74f51d\" class=\"forminator-input forminator-field--phone\" data-required=\"\" aria-required=\"false\" autocomplete=\"off\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"address-2\" class=\"forminator-field-address forminator-col forminator-col-6 \"><div class=\"forminator-row\"><div id=\"address-2-street_address\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-address-2-street_address_69d731a74f51d\" id=\"forminator-field-address-2-street_address_69d731a74f51d-label\" class=\"forminator-label\">Employer Address<\/label><input type=\"text\" name=\"address-2-street_address\" placeholder=\"E.g. 42 Wallaby Way\" id=\"forminator-field-address-2-street_address_69d731a74f51d\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" value=\"\" \/><\/div><\/div><\/div><\/div><div id=\"phone-3\" class=\"forminator-field-phone forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-3_69d731a74f51d\" id=\"forminator-field-phone-3_69d731a74f51d-label\" class=\"forminator-label\">Cell Phone<\/label><input type=\"text\" name=\"phone-3\" value=\"\" placeholder=\"E.g. +1 300 400 5000\" id=\"forminator-field-phone-3_69d731a74f51d\" class=\"forminator-input forminator-field--phone\" data-required=\"\" aria-required=\"false\" autocomplete=\"off\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-3\" class=\"forminator-field-name forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-3_69d731a74f51d\" id=\"forminator-field-name-3_69d731a74f51d-label\" class=\"forminator-label\">Parent Name<\/label><input type=\"text\" name=\"name-3\" value=\"\" placeholder=\"E.g. John Doe\" id=\"forminator-field-name-3_69d731a74f51d\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" \/><\/div><\/div><div id=\"text-3\" class=\"forminator-field-text forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-3_69d731a74f51d\" id=\"forminator-field-text-3_69d731a74f51d-label\" class=\"forminator-label\">D.O.B.<\/label><input type=\"text\" name=\"text-3\" value=\"\" placeholder=\"\" id=\"forminator-field-text-3_69d731a74f51d\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"text-4\" class=\"forminator-field-text forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-4_69d731a74f51d\" id=\"forminator-field-text-4_69d731a74f51d-label\" class=\"forminator-label\">S.S.#<\/label><input type=\"text\" name=\"text-4\" value=\"\" placeholder=\"\" id=\"forminator-field-text-4_69d731a74f51d\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"address-3\" class=\"forminator-field-address forminator-col forminator-col-6 \"><div class=\"forminator-row\"><div id=\"address-3-street_address\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-address-3-street_address_69d731a74f51d\" id=\"forminator-field-address-3-street_address_69d731a74f51d-label\" class=\"forminator-label\">Street Address<\/label><input type=\"text\" name=\"address-3-street_address\" placeholder=\"E.g. 42 Wallaby Way\" id=\"forminator-field-address-3-street_address_69d731a74f51d\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\" data-multiple=\"false\"><div id=\"address-3-zip\" class=\"forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-address-3-zip_69d731a74f51d\" id=\"forminator-field-address-3-zip_69d731a74f51d-label\" class=\"forminator-label\">ZIP \/ Postal Code<\/label><input type=\"text\" name=\"address-3-zip\" placeholder=\"E.g. 2000\" id=\"forminator-field-address-3-zip_69d731a74f51d\" class=\"forminator-input\" value=\"\" \/><\/div><\/div><\/div><\/div><div id=\"phone-4\" class=\"forminator-field-phone forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-4_69d731a74f51d\" id=\"forminator-field-phone-4_69d731a74f51d-label\" class=\"forminator-label\">Home phone<\/label><input type=\"text\" name=\"phone-4\" value=\"\" placeholder=\"E.g. +1 300 400 5000\" id=\"forminator-field-phone-4_69d731a74f51d\" class=\"forminator-input forminator-field--phone\" data-required=\"\" aria-required=\"false\" autocomplete=\"off\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-4\" class=\"forminator-field-name forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-4_69d731a74f51d\" id=\"forminator-field-name-4_69d731a74f51d-label\" class=\"forminator-label\">Employer Name<\/label><input type=\"text\" name=\"name-4\" value=\"\" placeholder=\"E.g. John Doe\" id=\"forminator-field-name-4_69d731a74f51d\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" \/><\/div><\/div><div id=\"phone-5\" class=\"forminator-field-phone forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-5_69d731a74f51d\" id=\"forminator-field-phone-5_69d731a74f51d-label\" class=\"forminator-label\">Work phone<\/label><input type=\"text\" name=\"phone-5\" value=\"\" placeholder=\"E.g. +1 300 400 5000\" id=\"forminator-field-phone-5_69d731a74f51d\" class=\"forminator-input forminator-field--phone\" data-required=\"\" aria-required=\"false\" autocomplete=\"off\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"address-4\" class=\"forminator-field-address forminator-col forminator-col-6 \"><div class=\"forminator-row\"><div id=\"address-4-street_address\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-address-4-street_address_69d731a74f51d\" id=\"forminator-field-address-4-street_address_69d731a74f51d-label\" class=\"forminator-label\">Employer Address<\/label><input type=\"text\" name=\"address-4-street_address\" placeholder=\"E.g. 42 Wallaby Way\" id=\"forminator-field-address-4-street_address_69d731a74f51d\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" value=\"\" \/><\/div><\/div><\/div><\/div><div id=\"phone-6\" class=\"forminator-field-phone forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-6_69d731a74f51d\" id=\"forminator-field-phone-6_69d731a74f51d-label\" class=\"forminator-label\">Cell Phone<\/label><input type=\"text\" name=\"phone-6\" value=\"\" placeholder=\"E.g. +1 300 400 5000\" id=\"forminator-field-phone-6_69d731a74f51d\" class=\"forminator-input forminator-field--phone\" data-required=\"\" aria-required=\"false\" autocomplete=\"off\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-12\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-12_69d731a74f51d\" id=\"forminator-field-text-12_69d731a74f51d-label\" class=\"forminator-label\">Child\/Children reside at the following address<\/label><input type=\"text\" name=\"text-12\" value=\"\" placeholder=\"\" id=\"forminator-field-text-12_69d731a74f51d\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><\/div><\/div><div tabindex=\"0\" role=\"tabpanel\" id=\"forminator-custom-form-1601--page-1\" class=\"forminator-pagination\" aria-labelledby=\"forminator-custom-form-1601--page-1-label\" aria-hidden=\"true\" data-step=\"1\" data-label=\"Page  1\" data-name=\"page-break-2\" hidden><div class=\"forminator-pagination--content\"><div class=\"forminator-row\"><div id=\"text-5\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-5_69d731a74f51d\" id=\"forminator-field-text-5_69d731a74f51d-label\" class=\"forminator-label\">Primary Insurance<\/label><input type=\"text\" name=\"text-5\" value=\"\" placeholder=\"\" id=\"forminator-field-text-5_69d731a74f51d\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"address-5\" class=\"forminator-field-address forminator-col forminator-col-12 \"><div class=\"forminator-row\"><div id=\"address-5-street_address\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-address-5-street_address_69d731a74f51d\" id=\"forminator-field-address-5-street_address_69d731a74f51d-label\" class=\"forminator-label\">Street Address<\/label><input type=\"text\" name=\"address-5-street_address\" placeholder=\"E.g. 42 Wallaby Way\" id=\"forminator-field-address-5-street_address_69d731a74f51d\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\" data-multiple=\"false\"><div id=\"address-5-city\" class=\"forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-address-5-city_69d731a74f51d\" id=\"forminator-field-address-5-city_69d731a74f51d-label\" class=\"forminator-label\">City<\/label><input type=\"text\" name=\"address-5-city\" placeholder=\"E.g. Sydney\" id=\"forminator-field-address-5-city_69d731a74f51d\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\" data-multiple=\"false\"><div id=\"address-5-zip\" class=\"forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-address-5-zip_69d731a74f51d\" id=\"forminator-field-address-5-zip_69d731a74f51d-label\" class=\"forminator-label\">ZIP \/ Postal Code<\/label><input type=\"text\" name=\"address-5-zip\" placeholder=\"E.g. 2000\" id=\"forminator-field-address-5-zip_69d731a74f51d\" class=\"forminator-input\" value=\"\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-7\" class=\"forminator-field-text forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-7_69d731a74f51d\" id=\"forminator-field-text-7_69d731a74f51d-label\" class=\"forminator-label\">Insurance Policy Holder<\/label><input type=\"text\" name=\"text-7\" value=\"\" placeholder=\"\" id=\"forminator-field-text-7_69d731a74f51d\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"text-8\" class=\"forminator-field-text forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-8_69d731a74f51d\" id=\"forminator-field-text-8_69d731a74f51d-label\" class=\"forminator-label\">D.O.B.<\/label><input type=\"text\" name=\"text-8\" value=\"\" placeholder=\"\" id=\"forminator-field-text-8_69d731a74f51d\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"text-6\" class=\"forminator-field-text forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-6_69d731a74f51d\" id=\"forminator-field-text-6_69d731a74f51d-label\" class=\"forminator-label\">S.S.#<\/label><input type=\"text\" name=\"text-6\" value=\"\" placeholder=\"\" id=\"forminator-field-text-6_69d731a74f51d\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"address-6\" class=\"forminator-field-address forminator-col forminator-col-6 \"><div class=\"forminator-row\"><div id=\"address-6-street_address\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-address-6-street_address_69d731a74f51d\" id=\"forminator-field-address-6-street_address_69d731a74f51d-label\" class=\"forminator-label\">Street Address<\/label><input type=\"text\" name=\"address-6-street_address\" placeholder=\"E.g. 42 Wallaby Way\" id=\"forminator-field-address-6-street_address_69d731a74f51d\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" value=\"\" \/><\/div><\/div><\/div><\/div><div id=\"phone-7\" class=\"forminator-field-phone forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-7_69d731a74f51d\" id=\"forminator-field-phone-7_69d731a74f51d-label\" class=\"forminator-label\">Home Phone<\/label><input type=\"text\" name=\"phone-7\" value=\"\" placeholder=\"E.g. +1 300 400 5000\" id=\"forminator-field-phone-7_69d731a74f51d\" class=\"forminator-input forminator-field--phone\" data-required=\"\" aria-required=\"false\" autocomplete=\"off\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-9\" class=\"forminator-field-text forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-9_69d731a74f51d\" id=\"forminator-field-text-9_69d731a74f51d-label\" class=\"forminator-label\">ID#<\/label><input type=\"text\" name=\"text-9\" value=\"\" placeholder=\"\" id=\"forminator-field-text-9_69d731a74f51d\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"text-11\" class=\"forminator-field-text forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-11_69d731a74f51d\" id=\"forminator-field-text-11_69d731a74f51d-label\" class=\"forminator-label\">Group#<\/label><input type=\"text\" name=\"text-11\" value=\"\" placeholder=\"\" id=\"forminator-field-text-11_69d731a74f51d\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"text-10\" class=\"forminator-field-text forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-10_69d731a74f51d\" id=\"forminator-field-text-10_69d731a74f51d-label\" class=\"forminator-label\">Copay<\/label><input type=\"text\" name=\"text-10\" value=\"\" placeholder=\"\" id=\"forminator-field-text-10_69d731a74f51d\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><\/div><\/div><div tabindex=\"0\" role=\"tabpanel\" id=\"forminator-custom-form-1601--page-2\" class=\"forminator-pagination\" aria-labelledby=\"forminator-custom-form-1601--page-2-label\" aria-hidden=\"true\" data-step=\"2\" data-label=\"Page  2\" data-name=\"page-break-3\" hidden><div class=\"forminator-pagination--content\"><div class=\"forminator-row\"><div id=\"text-13\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-13_69d731a74f51d\" id=\"forminator-field-text-13_69d731a74f51d-label\" class=\"forminator-label\">Secondary Insurance<\/label><input type=\"text\" name=\"text-13\" value=\"\" placeholder=\"\" id=\"forminator-field-text-13_69d731a74f51d\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"address-7\" class=\"forminator-field-address forminator-col forminator-col-12 \"><div class=\"forminator-row\"><div id=\"address-7-street_address\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-address-7-street_address_69d731a74f51d\" id=\"forminator-field-address-7-street_address_69d731a74f51d-label\" class=\"forminator-label\">Street Address<\/label><input type=\"text\" name=\"address-7-street_address\" placeholder=\"E.g. 42 Wallaby Way\" id=\"forminator-field-address-7-street_address_69d731a74f51d\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\" data-multiple=\"false\"><div id=\"address-7-city\" class=\"forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-address-7-city_69d731a74f51d\" id=\"forminator-field-address-7-city_69d731a74f51d-label\" class=\"forminator-label\">City<\/label><input type=\"text\" name=\"address-7-city\" placeholder=\"E.g. Sydney\" id=\"forminator-field-address-7-city_69d731a74f51d\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\" data-multiple=\"false\"><div id=\"address-7-zip\" class=\"forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-address-7-zip_69d731a74f51d\" id=\"forminator-field-address-7-zip_69d731a74f51d-label\" class=\"forminator-label\">ZIP \/ Postal Code<\/label><input type=\"text\" name=\"address-7-zip\" placeholder=\"E.g. 2000\" id=\"forminator-field-address-7-zip_69d731a74f51d\" class=\"forminator-input\" value=\"\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-14\" class=\"forminator-field-text forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-14_69d731a74f51d\" id=\"forminator-field-text-14_69d731a74f51d-label\" class=\"forminator-label\">Insurance Policy Holder<\/label><input type=\"text\" name=\"text-14\" value=\"\" placeholder=\"\" id=\"forminator-field-text-14_69d731a74f51d\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"text-15\" class=\"forminator-field-text forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-15_69d731a74f51d\" id=\"forminator-field-text-15_69d731a74f51d-label\" class=\"forminator-label\">D.O.B.<\/label><input type=\"text\" name=\"text-15\" value=\"\" placeholder=\"\" id=\"forminator-field-text-15_69d731a74f51d\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"text-16\" class=\"forminator-field-text forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-16_69d731a74f51d\" id=\"forminator-field-text-16_69d731a74f51d-label\" class=\"forminator-label\">S.S.#<\/label><input type=\"text\" name=\"text-16\" value=\"\" placeholder=\"\" id=\"forminator-field-text-16_69d731a74f51d\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"address-8\" class=\"forminator-field-address forminator-col forminator-col-6 \"><div class=\"forminator-row\"><div id=\"address-8-street_address\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-address-8-street_address_69d731a74f51d\" id=\"forminator-field-address-8-street_address_69d731a74f51d-label\" class=\"forminator-label\">Street Address<\/label><input type=\"text\" name=\"address-8-street_address\" placeholder=\"E.g. 42 Wallaby Way\" id=\"forminator-field-address-8-street_address_69d731a74f51d\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" value=\"\" \/><\/div><\/div><\/div><\/div><div id=\"phone-8\" class=\"forminator-field-phone forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-8_69d731a74f51d\" id=\"forminator-field-phone-8_69d731a74f51d-label\" class=\"forminator-label\">Home Phone<\/label><input type=\"text\" name=\"phone-8\" value=\"\" placeholder=\"E.g. +1 300 400 5000\" id=\"forminator-field-phone-8_69d731a74f51d\" class=\"forminator-input forminator-field--phone\" data-required=\"\" aria-required=\"false\" autocomplete=\"off\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-17\" class=\"forminator-field-text forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-17_69d731a74f51d\" id=\"forminator-field-text-17_69d731a74f51d-label\" class=\"forminator-label\">ID#<\/label><input type=\"text\" name=\"text-17\" value=\"\" placeholder=\"\" id=\"forminator-field-text-17_69d731a74f51d\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"text-18\" class=\"forminator-field-text forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-18_69d731a74f51d\" id=\"forminator-field-text-18_69d731a74f51d-label\" class=\"forminator-label\">Group#<\/label><input type=\"text\" name=\"text-18\" value=\"\" placeholder=\"\" id=\"forminator-field-text-18_69d731a74f51d\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"text-19\" class=\"forminator-field-text forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-19_69d731a74f51d\" id=\"forminator-field-text-19_69d731a74f51d-label\" class=\"forminator-label\">Copay<\/label><input type=\"text\" name=\"text-19\" value=\"\" placeholder=\"\" id=\"forminator-field-text-19_69d731a74f51d\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><\/div><\/div><div tabindex=\"0\" role=\"tabpanel\" id=\"forminator-custom-form-1601--page-3\" class=\"forminator-pagination\" aria-labelledby=\"forminator-custom-form-1601--page-3-label\" aria-hidden=\"true\" data-step=\"3\" data-label=\"Page  3\" data-name=\"page-break-4\" hidden><div class=\"forminator-pagination--content\"><div class=\"forminator-row\"><div id=\"textarea-1\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-1_69d731a74f51d\" id=\"forminator-field-textarea-1_69d731a74f51d-label\" class=\"forminator-label\">Please list all children who or will be patients of the Pediatric Center ( name , Birth date , Sex , Allergy )<\/label><textarea name=\"textarea-1\" placeholder=\"1- name , Birth date , Sex , Allergy \n2- ..... , ...... , ...... , ......\n3- ..... , ...... , ...... , ......\" id=\"forminator-field-textarea-1_69d731a74f51d\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:200px;\" maxlength=\"500\" ><\/textarea><span id=\"forminator-field-textarea-1_69d731a74f51d-description\" class=\"forminator-description\"><span data-limit=\"500\" data-type=\"characters\">0 \/ 500<\/span><\/span><\/div><\/div><\/div><\/div><\/div><div tabindex=\"0\" role=\"tabpanel\" id=\"forminator-custom-form-1601--page-4\" class=\"forminator-pagination\" aria-labelledby=\"forminator-custom-form-1601--page-4-label\" aria-hidden=\"true\" data-step=\"4\" data-label=\"Page  4\" data-name=\"\" hidden><div class=\"forminator-pagination--content\"><div class=\"forminator-row\"><div id=\"section-2\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Emergency Contact<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-5\" class=\"forminator-field-name forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-5_69d731a74f51d\" id=\"forminator-field-name-5_69d731a74f51d-label\" class=\"forminator-label\">Name<\/label><input type=\"text\" name=\"name-5\" value=\"\" placeholder=\"E.g. John Doe\" id=\"forminator-field-name-5_69d731a74f51d\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" \/><\/div><\/div><div id=\"text-20\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-20_69d731a74f51d\" id=\"forminator-field-text-20_69d731a74f51d-label\" class=\"forminator-label\">Relationship<\/label><input type=\"text\" name=\"text-20\" value=\"\" placeholder=\"\" id=\"forminator-field-text-20_69d731a74f51d\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"address-9\" class=\"forminator-field-address forminator-col forminator-col-4 \"><div class=\"forminator-row\"><div id=\"address-9-street_address\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-address-9-street_address_69d731a74f51d\" id=\"forminator-field-address-9-street_address_69d731a74f51d-label\" class=\"forminator-label\">Street Address<\/label><input type=\"text\" name=\"address-9-street_address\" placeholder=\"E.g. 42 Wallaby Way\" id=\"forminator-field-address-9-street_address_69d731a74f51d\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" value=\"\" \/><\/div><\/div><\/div><\/div><div id=\"phone-9\" class=\"forminator-field-phone forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-9_69d731a74f51d\" id=\"forminator-field-phone-9_69d731a74f51d-label\" class=\"forminator-label\">Home Phone<\/label><input type=\"text\" name=\"phone-9\" value=\"\" placeholder=\"E.g. +1 300 400 5000\" id=\"forminator-field-phone-9_69d731a74f51d\" class=\"forminator-input forminator-field--phone\" data-required=\"\" aria-required=\"false\" autocomplete=\"off\" \/><\/div><\/div><div id=\"phone-10\" class=\"forminator-field-phone forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-10_69d731a74f51d\" id=\"forminator-field-phone-10_69d731a74f51d-label\" class=\"forminator-label\">Cell Phone<\/label><input type=\"text\" name=\"phone-10\" value=\"\" placeholder=\"E.g. +1 300 400 5000\" id=\"forminator-field-phone-10_69d731a74f51d\" class=\"forminator-input forminator-field--phone\" data-required=\"\" aria-required=\"false\" autocomplete=\"off\" \/><\/div><\/div><\/div><\/div><button class=\"forminator-button forminator-pagination-submit\" style=\"display: none;\" disabled>Send<\/button><\/div><input type=\"hidden\" name=\"referer_url\" value=\"\" \/><input type=\"hidden\" id=\"forminator_nonce\" name=\"forminator_nonce\" value=\"22b95113ce\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F1602\" \/><input type=\"hidden\" name=\"form_id\" value=\"1601\"><input type=\"hidden\" name=\"page_id\" value=\"1602\"><input type=\"hidden\" name=\"form_type\" value=\"default\"><input type=\"hidden\" name=\"current_url\" value=\"https:\/\/starchoicepediatrics.com\/?page_id=1602\"><input type=\"hidden\" name=\"render_id\" value=\"0\"><input type=\"hidden\" name=\"action\" value=\"forminator_submit_form_custom-forms\"><\/form><\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"om_disable_all_campaigns":false,"site-sidebar-layout":"no-sidebar","site-content-layout":"page-builder","ast-site-content-layout":"default","site-content-style":"default","site-sidebar-style":"default","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"disabled","ast-breadcrumbs-content":"","ast-featured-img":"disabled","footer-sml-layout":"","theme-transparent-header-meta":"","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"default","ast-page-background-enabled":"default","ast-page-background-meta":{"desktop":{"background-color":"var(--ast-global-color-4)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"ast-content-background-meta":{"desktop":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"footnotes":""},"class_list":["post-1602","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/starchoicepediatrics.com\/index.php?rest_route=\/wp\/v2\/pages\/1602","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/starchoicepediatrics.com\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/starchoicepediatrics.com\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/starchoicepediatrics.com\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/starchoicepediatrics.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=1602"}],"version-history":[{"count":7,"href":"https:\/\/starchoicepediatrics.com\/index.php?rest_route=\/wp\/v2\/pages\/1602\/revisions"}],"predecessor-version":[{"id":1615,"href":"https:\/\/starchoicepediatrics.com\/index.php?rest_route=\/wp\/v2\/pages\/1602\/revisions\/1615"}],"wp:attachment":[{"href":"https:\/\/starchoicepediatrics.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=1602"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}